About one in 250 infants are born with congenital muscular torticollis (CMT) which is most often due to tightness in the sternocleidomastoid muscle or the muscle that connects the breastbone and the collarbone to the skull.
CMT is typically diagnosed within the first two months of a baby's life and is most often identified when the baby holds her head to one side, has limited neck movement, and/or has a small bump on the side of her neck.
Babies with torticollis may also develop asymmetrical head shape or positional plagiocephaly. CMT, often due to sleeping with the head turned to one side, puts constant pressure on the back of the head which leads to flattening. This may also be accompanied by frontal bulging. The asymmetry may cause spinal misalignment and uneven distribution of weight over the legs, leading to the development of orthopedic problems.
Because the condition limits a child's ability to turn his head to see, hear and interact freely with his environment, torticollis may lead to delayed cognitive development, delayed whole body awareness, weakness and difficulties with balance.
"Infants presenting with torticollis have less opportunity to track and look from the right to the left side and do not interact with their immediate environment with both hands symmetrically. They prefer looking to one side and are initially unable to roll from back to belly using their necks," shared Geetha Bharathan, PT, MS, physical therapist, Children's Specialized Hospital in Toms River, NJ.
Children's Specialized Hospital, with nine sites in New Jersey, is the largest pediatric rehabilitation health system in the country. The hospital serves children affected by traumatic brain injury, spinal cord injury and dysfunction, premature birth, autism, developmental delays, mental health issues and other life-changing injuries or illnesses.
Identification and Treatment
"Therapeutic intervention for a child with torticollis addresses the primary or secondary musculoskeletal, neuromotor and sensory impairments that arise from the muscular asymmetry of birth," explained Ellen Brennan, PT, DPT, physical therapist, Children's Specialized Hospital.
Physical therapy interventions aim to strengthen muscles, correct muscle imbalance and gain in cervical spine range of motion, and facilitate postural control, symmetry and biomechanical alignment along with normal soft-tissue and muscle-length tension.
Infants with torticollis present with developmental delays including rolling supine to prone, sitting, crawling and pulling to stand. They frequently crawl from one side with reduced elongation and weight bearing from the same side as torticollis, Bharathan said.
The strategy of the PTs at Children's Specialized Hospital's Toms River facility includes myofascial release using craniosacral therapy techniques, active stretching protocols using positioning strategies and functional play activities and neuro-developmental based handlings.
"Physical therapists must closely monitor a child with congenital muscular torticollis for the development of secondary impairments in strength and development until the primary impairment of musculoskeletal restriction is resolved," Dr. Brennan said.
Bharathan has consistently observed in her practice that impaired mobility and muscle tightness causes compensatory shortenings in the cranial base or small muscles of the posterior neck and upper cervical spine, anterior neck muscles and the floor of the mouth. This can interfere with oro-motor functions including swallowing, chewing and facial symmetry within a few months of birth.
At Children's Specialized Hospital, the PT program for torticollis uses a multisystem assessment to set functional and task oriented goals that allow the child to optimally interact with the environment in varied positions including supine, side lying, prone, sitting, quadruped and standing while maintaining midline head-neck orientation, according to Bharathan.
Prone play is important for the development of symmetrical shoulder strength and active elongation of the flexor musculature. Ipsilateral side lying is important for elongation of the lateral neck, trunk and hip musculature and development of strength of the contralateral musculature.
Physical therapist Adrienne Espin uses a special hold that stretches 7-month-old Dominick Mazzarella's tight muscles at Children's Specialized Hospital.
"An infant's neck is short and highly sensitive to passive ROM stretching even with no true restriction present," Bharathan shared. The therapists' gentle/light touch while working on cranial base releases along with other peripheral diaphragm releases softens the structures around the neck and shoulder without eliciting protective spasm/tightness.
The PTs believe that therapeutic taping may be used as an adjunct in infants and older children. Use of therapeutic taping on the ipsilateral scapula facilitates sustained muscle activation to correct the neck tilt. Therapeutic taping of the distal trunk and abdominal oblique muscles facilitates postural control.
According to Bharathan, physical therapy has been the primary intervention for torticollis; however, there are few studies to demonstrate the effectiveness of various interventions used by PTs. There is debate over the impact of torticollis on the developmental milestones and whether the condition needs any developmental intervention at all.
Bharathan is presently following this population and has observed delays in developmental milestones in the initial periods but sensitivity to various therapeutic interventions including cranio-sacral therapy, therapeutic taping and neuro-developmental handlings. "My focus is to study the impact of torticollis with or without plagiocephaly on developmental milestones and the effectiveness of therapeutic taping in this population," she said.
If Left Untreated
The child with CMT who does not receive treatment is at high risk for significant developmental asymmetry, according to Dr. Brennan. Activation of the contralateral neck musculature is more difficult when positional plagiocephaly develops.
In this case, the child chooses patterns for movement that use the ipsilateral strength and soft tissue limitation and avoid the contralateral weakness, causing further asymmetry in strength through the shoulder, trunk and hips. The older child with these secondary impairments of ipsilateral soft-tissue restriction and contralateral weakness presents with scoliosis, plagiocephaly and the associated activity and participation restrictions.
Infants with torticollis who go untreated may be at increased risk for early motor delay, global delay, impaired balance and coordination, delay in acquisition of gross motor skills, and reinforcement of altered movement patterns due to adaptive motor behavior.
"In the short term, infants who go untreated are at risk of progressive muscle and soft tissue tightness, inability to interact and play symmetrically, and positional deformation of skull," shared Bharathan. These infants may have decreased head-neck control, delayed developmental milestones, impaired trunk rotation with progressive loss of ROM in pelvic-hip complex and rib cage mobility and decreased postural control and balance responses.
Untreated infants over the long term may compensate with shoulder elevation, adducted arm with elbow flexion and medial rotation of opposite leg, and supination of feet. Significant facial asymmetry, mal-alignment in posterior cervical spine with compensatory changes in muscles and structures on the contra lateral side are not uncommon.
Parent Education is Key
Educating parents on repositioning and developmentally supportive positioning is essential to the proper progress of children with torticollis, according to Bharathan. Wedges, tiny bolsters, blanket rolls and horse-shoe shaped neck pillows are easily available and effective home positioning devices that assist in repositioning.
"Positioning and handling are imperative to prevent secondary impairments," shared Dr. Brennan. "The families are taught gentle stretching exercises and are encouraged to position the child in positions other than supine for play."
Bharathan recommends supervised tummy time at frequent intervals. She demonstrates different positions for infants to lie down and play and emphasizes the importance of changing the infant's orientation in the crib every day and placing blanket rolls under shoulders/chest to assist the infant in overcoming the effects of gravity.
"Gravity is the greatest challenge as well as facilitator for typical development and when faced with weak muscles, an infant will take the course of least resistance which leads to asymmetry," observed Bharathan.
The PTs instruct parents on properly positioning the infant during and after feeding to address postural control as well as gastrointestinal related issues like GER, spitting, abdominal bloating and constipation.
Parents are educated on repositioning during carrying, sleeping, playing and feeding that can be easily integrated into the child's daily routine. Parents learn to incorporate active stretching techniques, for example, during every diaper change.
The PTs focus on play activities that incorporate active stretching while visually tracking toys, such as reaching with hands and incorporating midline and bilateral integration and active chin tuck and neck flexion/extension and rotation. "We demonstrate these activities during our parent education and trainings so parents may continue them as part of the home program," Bharathan shared.
With proper gains in ROM, postural symmetry and meeting gross motor milestones, children are typically discharged with clear instructions on home activities. The PTs recommend active stretching components and activities like obstacle crawling and stair crawling, and use of swings, slides and other climbing equipment in the toddler areas of the playground.
Parents are encouraged to look for any regression observed in this population until 3 years of age. Parents must keep in mind, however, that with gains in every motor milestone, the child may regress temporarily but will always catch up as he masters the new skill.
"Parents should be comfortable with assessing signs of asymmetry as the child moves through the developmental progression and should be equipped with the necessary 'tools' for intervention should they notice a regression in head alignment," Dr. Brennan told ADVANCE.
As the infant gains strength in neck and trunk musculature, the caregivers are taught strengthening exercises that use age appropriate balance responses and transitions. The caregivers are taught infant massage and handling that will help to promote balanced, healthy tissues and somatosensory development.
Upon discharge from PT, the caregivers should be comfortable with passive and active range of motion exercises, according to Dr. Brennan. "Successful intervention for the child with torticollis is fully dependent on how successful the caregivers are in integrating treatment strategies into the child's daily routine," she observed.
Rebecca Mayer is senior regional editor of ADVANCE and can be reached at firstname.lastname@example.org